Puboperineales: muscular boundaries of the male urogenital hiatus in 3D from magnetic resonance imaging.

PURPOSE: The aims of this report are 1) to extend our previous two-dimensional magnetic resonance imaging study to create a three-dimensional image of the pelvic floor, including the puboperinealis, the most anteromedial component of the levator ani; 2) to clarify the historical controversy about this particular component of the levator ani; and 3) to present clinical implications of this muscle with respect to urinary continence and radical prostatectomy. MATERIALS AND METHODS: We reused the axial magnetic resonance imaging series from 1 of 15 men in a previous series. Analyze AVWTM allowed creation of three-dimensional images. Further, a movie clip of all three-dimensional images was developed and placed at the manuscript-dedicated Web site: http://www.mayo. edu/ppmovie/pp.html. RESULTS: Our three-dimensional images show how the puboperinealis portion of the levator ani flanks the urethra as it courses from the pubis to its insertion in the perineal body. CONCLUSIONS: The puboperinealis corresponds to muscles previously designated as the levator prostatae, Wilson's muscle, pubourethralis, and levator urethrae, among others. The images suggest that the puboperinealis is the muscle most responsible for the quick stop phenomenon of urination in the male. Our study supports the suggestion that weakening of the puboperinealis by transection, traction injury, or denervation may affect urinary continence after radical prostatectomy.

Benefit of adjuvant radiation therapy for localized prostate cancer with a positive surgical margin.

PURPOSE: Positive surgical margins are common after radical prostatectomy, and the role of adjuvant therapy in such cases is controversial. We determined the benefit of postoperative external beam radiation therapy in patients with margin positive prostate cancer with respect to biochemical progression or cancer recurrence. To decrease confounding factors that may affect the likelihood of biochemical progression our study was limited to men with organ confined cancer and a single positive margin. MATERIALS AND METHODS: We retrospectively evaluated the records of a nested matched cohort of 76 patients with pathological stage T2N0 prostate cancer and a single positive margin who underwent adjuvant radiation therapy within 3 months of radical prostatectomy. There was a positive margin at the prostatic apex in 35 cases, prostatic base in 18, posterior prostate in 11, urethra in 7, and prostatic apex and urethra in 5. These patients were matched 1:1 with 76 controls who did not receive adjuvant radiation therapy. Neither group received androgen deprivation therapy. Patients and controls were matched exactly for the margin positive site, age at surgery, preoperative serum prostate specific antigen, Gleason score and DNA ploidy. Biochemical relapse was defined as posttreatment PSA greater than 0.2 ng./ml. RESULTS: Overall there was significant estimated improvement plus or minus standard error in 5-year clinical and biochemical progression-free survival in 88%+/-5% versus 59%+/-11% of patients treated with adjuvant radiation therapy versus no radiation therapy (p = 0.005). No patient who received radiation therapy had local or distant recurrence, while 16% of controls had recurrence (p = 0.015). When stratified by site of margin positivity, the 5-year estimated clinical and biochemical progression-free rate in 18 cases and controls with a positive base margin was 95%+/-15% and 65%+/-13%, respectively (p = 0.02). The rate in 35 cases and cases with a positive apex margin was 95%+/-5% and 64%+/-15%, respectively (p = 0.07). Limited sample size precluded analysis of the other sites. CONCLUSIONS: Patients with localized prostate cancer and a singe positive surgical margin appear to have a lower rate of biochemical relapse at 5 years when adjuvant radiation therapy is administered. Definitive evidence of the beneficial effect of adjuvant radiation therapy for patients with involved surgical margins awaits conclusion of randomized clinical trials.

Prospective analysis of intraoperative frozen needle biopsy of solid renal masses in adults.

PURPOSE: We prospectively determined the accuracy of intraoperative needle biopsy of solid renal masses. MATERIALS AND METHODS: A total of 103 patients diagnosed with a solid renal mass and scheduled for surgery were prospectively evaluated. Radical or partial nephrectomy was performed, and biopsy of the surgical specimen was done twice through the tumor using an 18 gauge biopsy gun. Biopsy specimens of 106 tumors were sent for frozen sectioning, stained with hematoxylin and eosin, and reviewed by 2 independent pathologists blinded to each other and whole tissue specimens. Biopsy results were compared to whole tissue specimens. RESULTS: Specimens were obtained from 60 radical and 46 partial nephrectomy cases. Malignant neoplasms were present in 91 cases (86%). Overall, 15 cases (14%) were benign, of which 11 were oncocytomas. If lesions 4 cm. or less only were included in analysis, the incidence of benign lesions increased to 22%. Overall accuracy of the 2 pathologists was 76 and 80%. Nondiagnostic rates were 11 and 17%. Both observers incorrectly diagnosed 4 malignant lesions (5%) as benign, and incorrectly diagnosed 3 and 5 benign lesions (21 and 36%), respectively, as malignant. Analysis of values for both observers yielded a sensitivity of 77 and 84%, specificity 60 and 73%, positive predictive value 94 and 96%, and negative predictive value 69 and 73%. CONCLUSIONS: Overall frozen needle biopsy was accurate in more than 75% of cases and showed an excellent positive predictive value for carcinoma of more than 94%. Unfortunately, there was a large degree of inaccuracy for benign lesions and we do not recommend the routine use of intraoperative frozen needle biopsy to guide surgical decision making.

Urological complications after kidney-pancreas transplantation.

PURPOSE: Urological complications are common after kidney-pancreas transplantation. Predictors of urological complication after transplantation have not been established. We studied the impact of urological complications on allograft function. In addition we evaluated age at transplantation, diabetic years before transplantation and preoperative bladder function as predictors of allograft pancreatitis, postoperative retention and urine leaks. MATERIALS AND METHODS: Urological complications in 65 cases (38 men, 27 women, mean diabetic years 21 +/- 6, mean age 33 +/- 7 years) who had transplants between December 1987 and January 1995 were reviewed. Preoperative urodynamics in 50 patients (77%) and voiding cystourethrogram in 40 (62%) were analyzed. Kidney-pancreas transplantation was completed using bladder drainage techniques. RESULTS: Mean followup was 44 +/- 27 months (median 40, range 1 to 93). Urological complications in 51 patients (79%) included urinary tract infection in 59%, hematuria in 26%, allograft pancreatitis in 19%, duodenal leaks in 17%, ureteral lesions in 9% and urethral lesions in 6%. Eleven duodenal leaks (8 leaks in less than 1 month) required surgical treatment. Nine leaks recurred in 7 patients. Allograft pancreatitis occurred 32 times (range 1 to 9) in 12 patients. Three patients had ureteral obstruction and 3 had ureteral leaks. Preoperative urodynamics included detrusor hyperreflexia in 8 patients, detrusor areflexia in 19, indeterminate in 5 and normal in 18. The 1-year patient, kidney and pancreatic allograft survival rates were 92, 91 and 86%; 2-year survival rates were 89, 88 and 80%, and 5-year survival rates were 61, 59 and 55%, respectively. CONCLUSIONS: Urological complications were common after transplantation but did not adversely affect allograft survival in our series. Age at transplantation, diabetic years preceding transplantation and preoperative bladder function were not significantly correlated with allograft pancreatitis, postoperative urinary retention or urine leaks. A prospective analysis of postoperative bladder function should be completed to improve understanding and possibly reduce morbidity of urological complications after transplantation.

Renal plasmacytoma: Mayo Clinic experience and review of the literature.

Extramedullary plasmacytoma arising in the kidney is rare. Only 8 cases have been reported. Recently, we noted the ninth case, the second case seen at the Mayo Clinic. Clinically, the tumor mimics a renal cell carcinoma or a transitional cell carcinoma of the renal pelvis.

Spontaneous renal rupture during pregnancy.

Spontaneous rupture of the renal parenchyma or renal pelvis during pregnancy has been previously reported in 16 cases. In the case we describe in this report, the patient initially had right flank pain and nausea for 48 hours, which progressed to severe abdominal symptoms that necessitated exploratory laparotomy. Cystoscopic placement of a ureteral stent relieved the obstruction and allowed spontaneous healing of the renal pelvis. Dilatation of the urinary collecting system commonly occurs during pregnancy. Spontaneous rupture of the renal parenchyma or renal pelvis, however, is unusual and often associated with diseased kidneys. Our case is the 8th one of spontaneous rupture of the renal collecting system with no identifiable underlying pathologic condition and the 17th case of spontaneous renal rupture overall.

Morbidity of pancreas transplantation during cadaveric renal transplantation.

Simultaneous transplantation of the pancreas is an option for diabetic patients undergoing kidney transplantation to attempt to halt progression of diabetic complications, but the additional risk imposed by the procedure is unclear. Our aim was to determine the morbidity attributable to pancreas transplantation during simultaneous pancreas and kidney transplantation. We compared the first posttransplant year of 18 consecutive recipients of combined pancreas and kidney transplantation to 18 consecutive recipients of kidney transplantation alone. All patients received cadaver donor allografts between 1986 and 1989, and had type I diabetes mellitus with chronic renal failure. There were no differences in patient survival (94% both groups) or satisfactory renal allograft function (89% pancreas/kidney group, 83% kidney group) up to 18 months after transplantation. Eighty-eight percent of pancreas allografts were functioning satisfactorily at 18 months. There was a mean (+/- SD) of 1.5 +/- 1.0 acute rejection episodes per patient for the pancreas/kidney group compared to 0.8 +/- 6 for the kidney-only group (P less than 0.02). Cytomegalovirus infection and wound complications were each encountered more often after pancreas/kidney transplantation than kidney transplantation alone, and together with rejection accounted for a difference in days of hospitalization during the first year (71 +/- 34 vs. 27 +/- 13, P less than 0.001). We conclude that simultaneous pancreas transplantation during cadaver donor kidney transplantation accounted for more frequent rejection episodes, CMV infections, and wound complications. These complications resulted in more hospitalization for patients undergoing simultaneous pancreas/kidney transplantation than kidney transplantation alone.

Intravesical condyloma acuminatum with progression to verrucous carcinoma.

Condyloma acuminatum is a common form of venereal disease. Most patients with condylomata acuminata suffer from only the local cosmetic and irritative effects of the lesions. Few patients have progression to aggressive, regionally distributed lesions that can be life-threatening. We describe a forty-three-year-old white woman who had a seventeen-year history of scleroderma with extravesical and intravesical condylomata acuminata. During two years of conservative management with transurethral excision, electrocoagulation, and intravesical chemotherapy, the disease progressed to involve the entire bladder and resulted in obstructive renal insufficiency that required anterior exenteration and urinary diversion. The natural history of the disease is described, and the relevant literature is reviewed.

Histologic diagnosis of rejection by using cystoscopically directed needle biopsy specimens from dysfunctional pancreatoduodenal allografts with exocrine drainage into the bladder.

To determine the histologic features of rejection and to identify nonrejection causes of human pancreatic allograft dysfunction, we analyzed 31 needle biopsy specimens (17 pancreatic, 14 duodenal) obtained under cystoscopic direction from 15 dysfunctional pancreatoduodenal allografts with exocrine drainage into the bladder. Eight allografts undergoing rejection showed the most common histologic features of rejection to be diffuse mixed inflammatory infiltrates of pancreatic acinar tissue and duodenum wall. Diffuse infiltration of pancreatic acinar tissue by neutrophils was the earliest histologic change in rejection. Seven dysfunctional allografts not undergoing rejection ("nonrejection") showed a normal pancreas or various changes including acinar dilation with inspissation of secretions, fibrosis, cytomegalovirus inclusions, and enzymatic necrosis. The histologic changes in the duodenum paralleled those in the pancreas in both rejection and nonrejection allografts. We conclude that the histologic features of rejection in pancreatoduodenal allografts are distinctive. The changes seen in biopsy specimens accurately reflect the state of the graft and can be used to diagnose rejection and to identify other causes of graft dysfunction. Biopsy samples from the duodenum as well as the pancreas are diagnostically useful. The biopsy findings can be used to guide the clinical management of rejection and in the development of other noninvasive tests for rejection.

Pancreas transplantation at Mayo: II. Operative and perioperative management.

Better perioperative and operative management techniques have contributed to an improvement in the success rate of pancreas transplantation. Because of a shortage of donor organs, the criteria for acceptability of the allograft have been liberalized, and the development of techniques such as combined liver and pancreas procurement has increased allograft availability. Major advances have been made in organ preservation. Currently, pancreas allografts can routinely be stored for 18 to 24 hours. The technique of pancreaticoduodenal transplantation with a duodenocystostomy for the exocrine drainage is widely used. Experience with anesthetic and intensive-care unit management of these patients is accumulating. With the evolution of pancreas transplantation and with the help of the excellent transplant centers in our area, we developed a pancreas transplantation protocol and performed transplantation based on this protocol in 16 recipients at the Mayo Clinic from October 1987 through December 1988.

Differential diagnosis of hypoamylasuria in pancreas allograft recipients with urinary exocrine drainage.

We have studied the histopathologic correlates of a significantly decreased urinary amylase excretion rate (UAER) to determine its reliability in predicting the presence of cellular rejection within pancreas allografts drained via a duodenocystostomy. Significant hypoamylasuria in pancreas allograft recipients was defined as a diminution of greater than 50% in UAER sustained for greater than 36 hr and not associated with a decrease in serum amylase activity. We observed 18 such episodes of hypoamylasuria in 13 of 18 patients receiving pancreas allografts. Pancreaticoduodenal material was obtained during 11 of these episodes, one attempt failed, and for the remaining 6 episodes we obtained 3 renal allograft biopsy specimens. Histopathologic examination of the 14 specimens revealed cellular rejection in 9 (64%), fibrosis in 2 (14%), enzymatic necrosis in 1 (7%), cytomegaloviral pancreatitis in 1 (7%), and no abnormal features in 1 (7%). During these 14 episodes, a genetically identical renal allograft was present for 11 and showed signs of dysfunction in 9; however, the pancreatic histologic features suggested rejection in only 7 of the 9. Thus even the combination of hypoamylasuria and renal dysfunction in recipients of genetically identical organs was not fully reliable in predicting pancreas allograft rejection. In addition, the interval between organ implantation and onset of hypoamylasuria did not predict the histologic diagnosis. As with other solid-organ allografts, biopsy is a useful adjuvant for determining patient management in the presence of organ dysfunction.

Primary signet ring cell adenocarcinoma of the bladder.

Primary signet ring cell adenocarcinoma of the bladder accounts for less than 1 per cent of all primary bladder neoplasms. This tumor is insidious because of its subepithelial infiltrative nature, which makes diagnosis possible only late in the course of the disease. Survival is poor; greater than 50 per cent of the patients are dead within a year after diagnosis. Exenterative procedures offer the only hope of palliation; irradiation and chemotherapy have not been effective. We add 5 cases of primary signet ring cell adenocarcinoma of the bladder and 1 case of high grade transitional cell carcinoma of the bladder with signet ring cell foci to the 14 cases reported in the literature. Pathological correlation supports the origin of this neoplasm from totipotential transitional epithelium.

Incidental adenocarcinoma after open prostatic adenectomy.

Adenocarcinoma of the prostate occasionally is discovered incidentally in the enucleated gland at open prostatic adenectomy for benign disease. Among 468 men who underwent open prostatic adenectomy, unsuspected adenocarcinoma of the prostate was found on pathological examination in 28 (6.0 per cent). The tumors were stage A1 in 14 patients and stage A2 in 14. Careful tissue review resulted in reassigning 5 cases from stage A1 to stage A2. At a mean followup of 10.6 years disease progression had occurred in 4 patients with stage A2 disease. When stage A adenocarcinoma is discovered after open prostatectomy we recommend careful review of the surgical specimen for accurate staging, and adjuvant therapy for all patients with stage A2 disease an for younger patients (less than 65 years old) with stage A1 disease who have favorable life expectancies.

Prostatic involvement in Wegener's granulomatosis.

Wegener's granulomatosis involving the prostate gland is unusual. We report 3 cases of this condition in which typical necrotizing granulomas with vasculitis were seen histologically. These lesions may cause gross hematuria or obstructive voiding, including urinary retention. Management includes prostatectomy when the symptoms are severe but an initial trial of aggressive medical therapy may be successful. Treatment requires a knowledge of the natural history of Wegener's granulomatosis and its usual response to medical therapy.

The clinical spectrum of granulomatous prostatitis: a report of 200 cases.

Granulomatous prostatitis, reviewed in 200 tissue-diagnosed cases, occurred in 0.8 per cent of the benign inflammatory prostatic specimens. Often the disease followed a recent urinary tract infection (71 per cent) and was suspicious clinically for prostatic cancer (59 per cent). The diagnosis usually was made by needle biopsy or at transurethral prostatectomy (94 per cent). Most cases of granulomatous prostatitis were classified as nonspecific. The recently identified entity of post-transurethral resection granulomatous prostatitis was found in 49 patients. A proposed new category of granulomatous prostatitis that is secondary to systemic granulomatous diseases was documented in 6 patients. Most cases of granulomatous prostatitis resolved spontaneously and required no specific therapy.